Al Roker's Prostate Cancer - MedPage Today

For many of us, the year 2020 has been incredibly stressful. It's just one thing after another trying to knock us down. "Today" co-host and weatherman Al Roker is a perfect example. Besides having to cover a record-breaking Atlantic hurricane season (with 28 named storms, five of them major hurricanes), he announced in August that he would be undergoing shoulder replacement surgery, as we wrote about at the time.

And now, this past week, Roker revealed that he will be undergoing surgery again -- this time to treat prostate cancer.

As he told his fellow co-hosts: "It's a good news-bad news kind of thing. Good news is we caught it early. Not great news is that it's a little aggressive, so I'm going to be taking some time off to take care of this."

Roker's cancer was diagnosed when he was found to have an elevated prostate-specific antigen during a routine physical exam. A repeat test was also high, which led to an MRI of the prostate that showed a mass. Biopsy of the mass confirmed the diagnosis.

Roker will undergo surgery this week at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City. His surgeon, Vincent Laudone, MD, told the "Today" audience: "Fortunately his cancer appears somewhat limited or confined to the prostate, but because it's more aggressive, we wanted to treat it, and after a discussion regarding all of the different options -- surgery, radiation, focal therapy -- we settled on removing the prostate."

Roker said he wants to share his story to urge others, especially Black men, to have themselves checked regularly, so that a cancer, if detected, can be found early: "The problem for African American men is any number of reasons from genetics to access to healthcare, and so we want to make it available and let people know they got to get checked."

Prostate Cancer Discrepancies in Black Men

Prostate cancer is the most common cancer in men, and the third most common cancer diagnosis overall (behind breast and lung). According to the U.S. National Cancer Institute's SEER database, in 2020 there will be an estimated 191,930 new cases (10.6% of all new cancers), and 33,330 deaths (5.5% of all cancer deaths).

However, the incidence of new cases (per 100,000 persons) is 175.2 for Black men vs 102.3 for white men. The death rate (also per 100,000 persons) is nearly double for Black men -- 37.4 vs 17.9.

And if you look even closer at the data, it shows that even with low-grade prostate cancer, Black men are twice as likely to die than white men are. When a man is diagnosed with prostate cancer, the disease is given a grade, or score, based on how abnormal (or aggressive) the cancer cells look under a microscope. This system for assessing the aggressiveness of a prostate tumor is called the Gleason score.

Prostate cancer with a Gleason score of 6 is considered low grade, meaning it is less likely to grow and spread than cancer with a higher score (7 to 10). The vast majority of men diagnosed with localized, low-grade prostate cancer will die of something other than prostate cancer.

A 2018 study by Brandon Mahal and colleagues analyzed data from the main SEER database, which includes information on more than 400,000 men with prostate cancer who were followed for a median of more than 5 years.

In that analysis, a greater proportion of African American men than men of other races had died from low-grade prostate cancer 12 years after diagnosis (2.2% vs 1.4%). By comparison, the 12-year death rate from higher-grade prostate cancer was similar among African American men and men of other races (5.5% vs 5.3%).

Why is this the case? Aside from socioeconomic discrepancies, are there intrinsic differences in Black men that make them more susceptible to prostate cancer and more likely to die from the disease? Differences in tumor genomics, tumor location, and other factors are currently being examined by researchers.

In a September 2020 New England Journal of Medicine letter to the editor, Mahal and colleagues wrote about work done using next-generation genomic (DNA) sequencing on patients with prostate cancer at MSKCC and the Harvard/Dana-Farber Cancer Institute in Boston. The group evaluated almost 2,400 patients (2,109 white, 204 Black, and 80 Asian), approximately 60% of whom had primary disease, and the remainder had metastatic disease. The results showed:

• Among patients with primary disease, a higher proportion of Asian patients had more than 20 mutations (11.5%) compared with Black or white men (<5% each)

• FOXA1 gene mutations were found more frequently in Black (18.6%) and Asian men (37.8%) versus white men (11.9%). TP53 mutations were more common in white men vs Black men (20.6% vs 14.2%); mutations in the AR gene were uncommon, irrespective of race (<3%)

• The frequency of genes with "actionable" mutations (approximately 17%-22%) and the frequency of mutations in DNA-repair genes (approximately 10%-14%) did not markedly differ among groups ("actionable" mutations are those that have a specific therapy "targeted" at these mutations)

Mahal's group concluded: "Clinically significant alterations may occur at different frequencies across races. This finding could have implications for prognosis, response to therapy, and enrollment of minority populations in clinical trials and precision oncology studies."

Another study looked at 20 prostatic cancer (PC)-associated biomarkers. Six showed statistically significant differential expression in African American men compared with white men. The authors concludes that these PC biomarkers predict the risk of "clinicopathologic outcomes in an ethnicity-dependent manner ... [and] may explain in part the biologic contribution to ethnic disparity in PC outcomes between white and Black men."

Another possibility is that traditional biopsies may be more likely to miss areas of high-grade prostate cancer in Black men than in men of other racial/ethnic groups, leading to a higher likelihood of misdiagnosis of low-grade disease.

A 2014 study found that African American men are more likely than white men to have tumors in the anterior region of the prostate, which is harder to reach with a traditional transrectal biopsy. In addition, these tumors are of a higher grade and larger volume. The authors suggested that "enhanced imaging or anterior zone sampling may detect these significant anterior tumors, improving the outcome in black men [especially in those] considering active surveillance."

The largest coordinated research effort to study biological and non-biological factors associated with aggressive prostate cancer in Black men has begun. The $26.5-million study is called RESPOND, or Research on Prostate Cancer in Men of African Ancestry: Defining the Roles of Genetics, Tumor Markers, and Social Stress. It will investigate environmental and genetic factors related to aggressiveness of prostate cancer in Black men to better understand why they disproportionally experience aggressive disease -- that is, disease that grows and spreads quickly -- compared with men of other racial and ethnic groups.

RESPOND is supported by the National Cancer Institute (NCI) and the National Institute on Minority Health and Health Disparities (NIMHD), both parts of the National Institutes of Health, as well as by the Prostate Cancer Foundation. The NCI funding will be provided from the 21st Century Cures Cancer Moonshot Initiative.

NIMHD Director Eliseo Pérez-Stable, MD, commented in a news release when the study was announced, "This study, which is combining state-of-the-art molecular approaches with social and environmental science, will help unravel the complex interactions of biological, behavioral, and environmental factors that contribute to excess prostate cancer burden and poorer outcomes in African American men, allowing development of tailored approaches for prevention, diagnosis, and treatment in this population."

Sources: SEER, NCI, NIH, NIMHD

Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.